Anticoagulant reversal: expert coalition issues guidelines

Takeaway

• For bleeding patients taking anticoagulants, reversal or factor replacement may be necessary but should not crowd out supportive care, source control, consults.

Why this matters

• Anticoagulant use is rising, thanks to expanding indications, growing geriatric population.

Description

• Multidisciplinary consensus on:
  • Assessing bleeding patients who take anticoagulant.
  • Reversing anticoagulants, replacing coagulation factors.
  • Definitions of life-threatening bleeding, bleeding at critical site, and emergency surgery or urgent invasive procedure.

Key details

• To determine who requires reversal/replacement, consider, e.g.:
  • Amount, time of last dose.
  • Whether bleeding is life-threatening or in critical site.
• If reversal/replacement is necessary:
  • Do not neglect supportive care.
  • Control source via compression, surgery, endoscopy, or interventional radiology.
  • Use labs to risk-stratify and identify comorbidities.
• Nonbleeding patients may require reversal if:
  • Emergent procedure needed.
  • They overdosed on vitamin K antagonist (VKA).
• Reversal options:
  • Antiplatelet agents: consider desmopressin (DDAVP, Ferring).
  • Platelet transfusion is of unclear benefit.
  • Apixaban (Eliquis, Bristol-Myers Squibb) and rivaroxaban (Xarelto, Janssen): andexanet alfa (Andexxa, Portola; all FDA-approved).
  • Dabigatran (Pradaxa, Boehringer Ingelheim): idarucizumab (Praxbind, Boehringer Ingelheim; FDA-approved).
  • VKAs: 4-factor prothrombin complex concentrate (PCC; Kcentra, CSL Behring; FDA-approved); multiple unapproved options.
  • Direct oral anticoagulants: (activated) PCC (limited data).
• For overdose:
  • Monitor for 2-5 half-lives.
  • Consider Poison Control consult, especially if, e.g., synthetic VKAs.